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Case Presentation

Case Presentation. 25 yo g2p1 at 41 weeks Induction scheduled and begun Long and slow, AROM finally That night, at home… What went wrong? How can this be avoided in the future?. Patient Safety and Human Factors Engineering. LTC Gary W. Clark, MD MPH. Define: Error Define: Patient Safety.

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Case Presentation

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  1. Case Presentation • 25 yo g2p1 at 41 weeks • Induction scheduled and begun • Long and slow, AROM finally • That night, at home… • What went wrong? • How can this be avoided in the future?

  2. Patient Safety and Human Factors Engineering LTC Gary W. Clark, MD MPH

  3. Define: Error • Define: Patient Safety

  4. To Err is Human • Errors will always happen • They may be irrelevant • We need to design systems that mitigate errors before they harm patients • It is not about blame

  5. Patient Safety • Identification and control of hazards that could cause harm to patients • Prevention of harm/injury to patients • Providing a safe environment in which to practice • Quality care must be safe care

  6. Semantics or Reality? • Wrong leg is amputated • Wrong medication is dispensed • Diagnosis is too late to save a patient with meningitis • You almost do an LP on the wrong pt • Focus not on blame but on pt safety

  7. Adverse Events • Unwanted incidents • Therapeutic misadventures • Iatrogenic injuries • Adverse occurrences • Result from commission and omission • Does it really matter who did it?

  8. Who Cares? Medical errors may be common, but seldom do patients get harmed by them…

  9. Causes of Death US 2000 • Heart disease 710,760 • COPD/Asthma 122,000 • Diabetes 69,301 • Alzheimer’s 49,558 • MVA 41,994 • Medical Error (‘00) 44,000-98,000 Inpt only (‘04) 191,000

  10. Studies have shown IOM study based on these data • ICU: 1.7 events/pt/day • IM rounds: 50% of pts w/1-10 events • FM: 50% of patients with events

  11. 96-98% Reliability in Hospitals 99.9% reliability is: • 1 hour of unsafe drinking water per month • 2 unsafe landings at O’Hare per day • 16,000 pieces of lost mail per day

  12. 96-98% Reliability in Hospitals • 22,000 checks deducted from wrong account per hour • 20,000 incorrect prescriptions/year • 500 incorrect operations each week • Actual numbers for hospitals are 20-40x

  13. So why do this many mistakes happen?

  14. Personal approach Focus on a person Poster campaigns New procedures Discipline methods Threat of litigation Blame, shame Retrain System approach Focus on conditions and environments Build fault tolerance into the system Creating a better system It is Usually the System

  15. Is MAMC a No-Fault System? • How do we report mistakes? • How is this information handled by the hospital? • What venues do we use to discuss mistakes?

  16. Population Health Reduce disease • Look for risk factors • How do they contribute to disease? • Reduce or eliminate risk factors • Mitigate the effect on patients

  17. Patient Safety Reducing adverse events • Look for hazards • How do they contribute to adverse events? • Find solutions to reduce/eliminate hazards • Mitigate impact on patient safety

  18. Human Factors Engineering • Designing systems, devices, tools to fit human capabilities and limitations • Get info re: hidden needs of end-user • Unexpected interactions between the system and the end-user

  19. Human Factors Engineering Well studied in • Aviation • Nuclear power • Space flight • Software design • Palm pilots Why?

  20. Radar Scope to Detect “enemy” ships

  21. Performance Graph 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

  22. Performance Graph 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

  23. How can we move the curve upwards? 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

  24. It is Easy to Miss Stuff • Look at the next slide • Count the number of words in the paragraph that are repeated

  25. Exercise The last time we got together to camp in Nova Nova Scotia we we decided that it would be too cold to sleep in a tent. So, I called the motel motel that was located near Peggy’s Cove on on top of the hill. We should call each other and talk about these plans once and for all. If you cannot call me, the the best way to get in touch is by fax fax machine.

  26. Exercise The last time we got together to camp in Nova Nova Scotia we we decided that it would be too cold to sleep in a tent. So, I called the motel motel that was located near Peggy’s Cove on on top of the hill. We should call each other and talk about these plans once and for all. If you cannot call me, the the best way to get in touch is by fax fax machine. Answer is “3”?

  27. Exercise The last time we got together to camp inNova Nova Scotia we we decided that it would be too cold to sleep in a tent. So, I called themotel motelthat was located near Peggy’s Cove on on top of the hill. We should call each other and talk about these plans once and for all. If you cannot call me, the the best way to get in touch is by fax fax machine. Or is the answer 6?…or is it 14?

  28. Now, State the Color of the Text as Fast as You Can… Green Yellow Red Blue Row 1 Green Yellow Blue Red Row 2 Green Red Yellow Blue Row 3

  29. Again, State the Color of the Text as Fast as You Can… Red Blue Green Yellow Row 1 Yellow Green Blue Red Row 2 Green Yellow Blue Row 3 Red

  30. “Tell the nursing student to attach the oxygen mask and tubing to the green spigot”

  31. What could you do to fix this problem?

  32. Weaker vs. Stronger Remedy Better Make sure to use the correct color Adaptor!?

  33. Sources: Medical Mistake Left Newborn In Coma KITV-TV HONOLULU - A medical mistake at Tripler Army Medical Center has left a newborn baby in a coma with severe brain damage. Sources familiar with this case tell KITV 4 News that Tripler officials apologized to the family of a baby boy born there in January after he was mistakenly given carbon dioxide right after birth, instead of oxygen. The baby boy was born Jan. 14 at Tripler Army Medical Center during a scheduled cesarean section delivery, sources told KITV 4 News. They said medical personnel mistakenly gave him carbon dioxide immediately after birth instead of oxygen. Sources said the operating room may have been set up incorrectly.

  34. Medical Software Correlation - Pharmacist uses 95% of time - “Enter” button to enter data - Pharmacist uses 5% of time - “Spacebar” to enter data

  35. Do we have any computer systems like this?

  36. HFE and Patient Safety • We often have a “pre-set” focus during interpretation • How much can a clinician attend to in an ICU room? • Patient • Monitor • IV Pump

  37. Ball passing video

  38. Normalization of Complexity • Encouraged • Mastery of the complex becomes the normal strategy • No regard for reasonableness or necessity of complexity

  39. Baseline Drawer (“Laundry hamper”)Range = 2:43-3:58 min, Avg=3:07 min Note the multiple orientations

  40. Code Cart Drawer Fifth VersionRange = :55-1:25 min, Avg=1:08 Note the lack of labels for each spot

  41. Human Factors Engineering Your stories of • Adverse events • Close calls • Human factor engineering issues Cryo Gun ACLS drugs Induction of 35 week gestation ACLS on stab wound victim

  42. Take Home Points • Adverse events are common • People are injured or die • It is the system, not the person • Human factors engineering helps • Look for hazards and address them

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